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Skills mix to achieve universal health coverage: a global systematic review and country case studies on roles and impact of mid-level health workers

Second Global Symposium on Health Systems Research

The Global Health Workforce Alliance (the Alliance) organized a session on mid-level health workers (MLHWs) at the Second Global Symposium on Health Systems Research in Beijing, China. The objective of the session was to facilitate dialogue on key issues and strategies relevant for scale-up of MLHWs in national health systems. The session included sharing of best practices, challenges and experiences; and identified effective strategies to translate evidence into policy and implementation to effectively scale up MLHWs towards achieving universal coverage.

The session emphasized that the term and concept “MLHW” is not something new; rather, it is a re-naming of what was called “auxiliary health workers” for many decades. Auxiliary health workers have always been important members of health teams. What has changed is the nature of and skills mix found in health teams. All panelists agreed that multi-skilled health teams are essential to primary care service delivery and to scale up access to care in HRH crisis areas. Members of the panel also highlighted that, when referring to the activities performed by mid-level providers, “skill mixing” should be considered the appropriate term and concept to use as opposed to “task shifting”, since the latter may restrict the scope of tasks MLPs can perform.

Panelists, answered questions from the audience concerning the failure to turn what it is known on the value of MLPs into policy. Dr Suwit Wilbolpoprasert, Ministry of Health, Thailand cited one of the main reasons to be health workers being regulated by ministries of health. Dr Anders Nordstrom, (Ministry of Foreign Affairs, Sweden) , was of the view that WHO has played a role in this since it has not adequately emphasized the importance of MLPs and task shifting as key solutions to the HRH crisis. He also suggested that a different mix of skills in health teams is required today alongside the need to understand and challenge the political context surrounding HRH.

Members of the audience also shared their views. They expressed the need to avoid using competitive language when talking about health workers to prevent conflicts amongst health workers. Professional Organizations were also seen as a major barrier. They also stated that policymakers regard for MLHWs as lower-trained people and, therefore considered “risky” as health workers. According to the audience, MLHWs need a career track, to be able to fully grasp their prospects and to have training possibilities. There is a need for a paradigm shift, away from a vertical vision. A critical problem is to know whether obstacles are part of health workers’ philosophy or part of society in general.

Another important question raised was concerned ways to ensure medical doctors do not feel resentment from task shifting. Dr Suwit Wilbolpoprasert, emphasized the need to make changes in medical education. He stated, medical education at the community level - as part of health teams with midwives, dentists, pharmacists, and nurses - may be the best place to train physicians; rather than in isolated areas of specialization in medical schools. This approach would prevent physician resentment from task shifting because team approach would be a part of a physician’s basic medical education. David Sanders, from the University of Western Cape, South Africa, instead, pointed out the importance of the political context. Finally, Prof Luis Huicho, Universidad Peruana Cayetano Heredia, Lima, Peru, felt that more evidence is needed to understand what the most powerful motivators for health workers are.

In summary, there was wide agreement that:

MLPs are essential members of health teams,

task shifting sends a competitive message so focus should be on appropriate ‘skill mix’ and ‘task sharing’,

all members of a health team need to be respected,

MLPs need opportunities for training and career advancement,

the political context surrounding HRH should not be ignored,it would be helpful if the WHO would state that the concept of “health worker” needs a team approach.

The session, attended by approximately 70 people, was greatly appreciated. Members of the audience were so engaged in the debate that there was not enough time for everyone who wanted to speak to provide their views.